Friday, August 22, 2008

Fifteen days of blogging for health care reform: End of the road

Guest post by Skylanda.

Several months ago, I was admitting a gentleman to the general medicine floor of the university hospital. Per protocol, I gave him our standard speech about how we don’t expect him to drop over dead during this admission, but in case he did, we needed to know in advance if he would like us to make all attempts at resuscitation or let him to die peacefully. I promise, the speech came out a good deal more gently than that; the first time an intern has to ask this it usually feels awkward, but after a several dozen times, you get down a speech that you feel comfortable with, that patients don’t recoil in horror to, and you make it part of your routine admission. It’s quite far from the weirdest thing we do every day, believe me (rectal exams: now there‘s one of the weirdest things we do every day).

“Well,” this gentleman said thoughtfully, “I guess you can bring me back. Just so long as they don’t keep me alive like a vegetable or something. I just don’t want to be a burden on anyone.”

This a guy who was being admitted for the sixth time in as many months for one of those diseases you develop by following a particular lifestyle. He had been abstaining from his vice of choice for some number of weeks, and had been asymptomatic of the disease it had been causing, but that evening something had provoked him to hit up one of the local houses of marginal repute. He sat down at a slot machine, he indulged, he landed on our floor via ambulance an hour later, groaning in pain and wondering if this was the event that was finally going to get him.

His response was not new; you might have thought it - or said it - yourself if you’d been asked the question. But it brings up the question: what does it mean to be a burden? Who is a burden on the system? More aptly, is any one of us not a burden on the system? What do we do with those who cost so much for individual care that we are forced to consider the financial consequences of that care on the larger picture - that is, the health we cannot provide to others because of the gross expenditure we are pouring into one person?

There is much rhetoric around the idea of being a burden, or of not wanting to become one. Most of this comes from healthy able-bodied people who do not actually have to face down the question - now, today - of whether or not they want their own burdensome self taken off the human map. Much of this rhetoric is sanctimonious in nature: “I would never want to live like that,” it says of the disabled body or ill body; “Kill me if I ever need a machine to help me breathe, or a tube to help me eat,” it threatens. This rhetoric makes movies like Million Dollar Baby; it creates Jerry Lewis telethons where the disabled are reified as hapless children incapable of anything but receiving your benevolent charity; it finds tragedy in disability, and redemption in a throw-yourself-on-the-fire-for-the-greater-good stance from the disabled, who usually have zero interest in throwing themselves on fires for the comfort of others. It inspires a hypervigilant but entirely necessary form of activism known as the disability rights movement, spearheaded by people with precisely those conditions who have decided that indeed, they would not like to be invited to die just because they require a tube to eat or a wheelchair to move about the world in.

But let’s back up a second. What does it mean to be a burden? On one hand, you could define a “burden” as someone who requires so much individual care that it profoundly disrupts the lives of the people around them, reorienting entire families around the care of a sick member. Financially, you could call a “burden” anyone who draws more off the health care system than they pay into it. The popular rhetoric on this topic would have you believe that the follow groups are the most frequent offenders in the category of “burdens” on the system: Illegal immigrants. Those who frequently visit the emergency room instead of accessing primary care. Severely disabled people. Uninsured patients who don‘t pay their hospital bills. People who smoke. People who don’t eat right and don’t exercise. Drinkers. Drug addicts. Fat people.

I beg to differ with that rhetoric. I argue that just about every last one of us is a burden on the system. There are many reasons why, and here is the first: because at the current cost of medical services, any of us who use any quantity of medical services in a given year - even those of us paying out the nose to maintain private insurance premiums - are likely using more resources than we are paying in. In one particular year of medical school - when I was grousing about paying cash out of student loan funds (which I will be repaying, with interest, for the next thirty years) for a group health insurance plan, I was treated for two benign conditions: chronic migraines, and an allergic reaction to a skin infection that required a long course of powerful antibiotics overseen by a dermatologist. Nothing profound, nothing terribly out of the ordinary. But unless my insurance company was bargaining far lower prices than were showing up my billing summaries, those alone racked up costs in excess of my total premiums. There I am: a burden on society. Few but the healthiest people won’t suddenly rack up costs in excess of their contribution even with just a couple of routine conditions - this is one reason (among myriad others) why premiums go up every year but never seem to quite catch up.

The second way most people become a burden on the system is by outliving their own health. You can be the most good eatin’, clean livin’, regular exercising’ guy or gal on the block, but eventually something is going to get you. And unless that something kills you dead (say, a full frontal bus wreck or a drop-dead cardiac arrest) before you have any chance to haul your rear end into your local health care provider, it doesn’t matter how old you got to be before that bad stuff caught up with you: you too are now a burden on society.

This is the dirty little secret of the public health world we like to call the “prevention paradox”: that good preventive care saves money now, but it generally does not save money in the long run. Here is why: people who stay healthy live longer and take incrementally more out of the system year by year using those preventive and routine services than someone who dies younger. And eventually, all those healthy people will get old, and they will die of something; in the months just before they do just that, they will - on average - run up some astronomical medical bills that short circuit all the savings they accrued over all those long years of good health.

The irony of course is that we spend ungodly sums of money in America to keep people alive during the time of their lives when they are least likely to benefit. Where we hedge about vaccinations for children and click a mouse to donate one hundredth of a free mammogram to a middle-aged adult, we seem quite happy to hurl sums worthy of the national defense budget into stretching life out another month or two when the writing is so clearly on the wall. Bang per buck, keeping a ninety year-old alive for another three months at the cost of four hospital stays does not make near as much sense as getting the whole population to ninety as healthy and happy as can do. You better enjoy those last six months - hospitalizations, crises, dialysis, adult diapers, and all - because they will cost you (or, that is, cost the collective us) some hundreds of thousands of dollars to drag that end heroically out to the last possible second.

And since we are all playing a part in this all-consuming system suck together, it is time to dispense of the notion of who is a bigger burden than whom else. Your contribution to the insurance pool - assuming you do pay insurance premiums - is a poor marginal quantity compared to what you will in all likelihood one day draw off of it. The leg you stand on when feeling self-righteous about your contribution over the contribution of the illegal alien who picks your grapes, or the guy down the street who is that much fatter than you, or the kid with cerebral palsy who needs monthly health maintenance, or the smoker next door, is an ephemeral and illusory source of self-righteousness indeed. Promoting health for the sake of quality of life, controlling cost along the way, and doing some serious soul searching about our emphasis on end-of-life heroics over end-of-life comfort…these are the things that diverge the pathway of “burden” from the pathway of reasonable cost. Not whether you pay your premiums or not, not whether you were born in the country or not, not whether you use a wheelchair, and not whether your BMI fits between the numbers 20.1 and 24.9. Thusfar, the most of us can wear that scarlet B for “burden” without standing out from any kind of crowd.

As for the gentleman I admitted to the hospital that night, he survived just fine to be a burden for another day. Good for him.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

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